MEDICARE: KENNETH JOHN MEKELBURG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	13801R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619975166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH JOHN MEKELBURG M.D.

Provider Business Mailing Address
First Line	:	2525 VIKING DRIVE
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2103
Country	:	US
Telephone Number	:	318-841-2525
Fax Number	:	318-681-6812

Provider Business Practice Location Address
First Line	:	2525 VIKING DRIVE
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2103
Country	:	US
Telephone Number	:	318-841-2525
Fax Number	:	318-681-6812

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	03/29/2012

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